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Home My Public Portal About9570 LAS TUNAS DR_Miscellaneous__ WORKERS'COMPENSATION DECLARATION CE 875 (11-84) MISCELLANEOUS APPLICATION CE 875 I hereby affirm that I have a certificate of consent 'self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec. 3800,Lab.C). Policy No Company FOR APPLICANT TO FILL IN BUILDING -76 � fN/. �S /,I /A ADDRESS •• JJ(_ Certified copy is hereby furnished. UILDING LOCALITY C ADDRESS Certified copy is filed with the county building inspection ,ADDR ET NEAREST department. ` CROSS ST. L U Date Applicant EAREST DISTRICT NO. GR P TYPE PROC S ED BY CERTIFICATE OF EXEMPTION FROM WORKERS' `VROSS sr `a rU� � colvsT / LEGAL V COMPENSATION INSURANCE DESCRIPTION I LOT NO. BLOCK MAP HIGHWAY NOOF NO (CIRCLE) STATE MAJOR SECOND LOCAL BLOGS. (This section need not be completed if the work involved TRACT NOW. ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars ($100) or less.) USE of I certify that in the performance of the work for which this SIZE OF LOT EXISTING BLDG. >07 permit is issued, I shall not employ any person in any manner V OWNER y so as to become subject to the Workers' Compensation Laws OCCUPANCY GROUP � AIL < / CD Date Applicant ADDRESS g37 a (VN�S q� TEL' OCCUPANT LOAD NOTICE TO APPLICANT If, after making this Certificate of clrY l U NO Z�r6 ?/ N Exemption, you should become subject to the Workers' z Compensation provisions of the Labor Code, you must forth- APP ICATION FOR EXIT HARDWARE — with comply With such provisions or this permit shall be TRAILER USE ❑ GE LOGY INSPECTION ❑ No Spec. Know]. ❑ deemed revoked. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION Panic Devices I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMI ❑ (LIST ITEMS BELOW) 9 (commencing with Section 7000) of Division 3 of the Busi- NO. OF EXITS ness and Professions Code,and my license is in full force and effect. PARKING REQ•D D PROVIDED SPACES License Number Lie. Class LIMITED TIME USE Contractor Date DATE DATE 1 am exempt from the licensing requirements as I am a FROM: TO' licensed architect or a registered professional engineer SIZE OF NO. OF INSPECTOR S acting in my professional capacity (Section 7051, Bus ISTING BLDG. STORIES SIG ATURE mess and Professions Code). //�/�/� FINAL APPROVAL Vrl E Lie.or Reg.No. Date PRESENT USOF BUILDING � HOME OWNER-BUILDER DECLARATION NO. OF EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 2 7 7 b 9 A License Law for the following reason (Section 7031.5, Busi- ness and Professions Code): NO. PARKING I, as owner of the property, will do the work and the SPACES PROVIDED # °(° ° ° 8$ structure is not intended or offered for sale (Section • • o 0 0 • •2 7044,Business and Professions Code). CONSTRUCTION LENDING AGENCY PROPOSED USE of BUILDINGeQilm 0 8,2 7 8 7 I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec. 3097,Civ.CJ Lender's Name PROPOSED MAX. OCC. Lender's Address PF PERMIT FEE I certify that I have read this application and state that the a1i'lll/ above information is correct.I agree to comply with all County ISSUANCE FEE ordinances and State laws relating to building construction, and hereby authorize pies atrves of this C�n �iuyr to enter TOTAL FEE u on the ve n ed erty for inspe�opos �. SEE REVERSE FOR EXPLANATORY LANGUAGE O Signature of Permittee Date WORKERS'COMPENSATION DECLARATION CE 8454 (2 80) MISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNTY OF LOS ANGELES BUILDING AND SAFETY DIVISION Insure, or a certificate of Workers'Compensation Insurance,or a certified copy thereof(Sec 3800,Lab C.) 0 Policy No Company FOR APPLICANT TO FILL IN BUILDING r ADDRESS ❑ Certified copy Is hereby furnished. BUILDING ADDRESS 5�70IAS / LOCALITY _ ❑ Certified copy is filed with the county building Inspection NEAREST department LOCALITY CROSS ST Date Applicant NEAREST DISTRICT NO. GROUP TYPE P D BY CROSS ST CONST �. CERTIFICATE OF EXEMPTION FROM WORKERS' LEGAL • _ COMPENSATION INSURANCE DESCRIPTION LOT No BLOCK P NY NO (CIRCLE) STATE MAJOR SECOND LOCAL CL NO OF 6LDG5 (This section need not be completed if the work involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS O by the permit is for one hundred dollars ($100) or less.) U USE OF SIZE OF LOT EXISTING BLDG. tr I certify that In the performance of the work for which this 0 permit Is Issued, I shall not employ any person In any manner OWNER I— so as to become subject to the Workers' Compensation Laws AIL OCCUPANCY GROUP W M ADDRESS iL Date Applicant TEL NOTICE TO APPLICANT If, after making this Certificate of cITYr jL, No — OCCUPANT LOAD Exemption, you should become subject to the Workers' APPLICATION FOR EXIT HARDWARE Compensation provisions of the Labor Code, you must forth- with comply with such provisions or this permit shall be TRAILER USEGEOLOGY INSPECTION deemed revoked ❑ ❑ No Spec. Knowl. LICENSED CONTRACTORS DECLARATION OCCUPANCY INSPECTION 10 Panic Devices ❑ I hereby affirm that I am licensed under provisions of Chapter SAFETY PERMIT ❑ (LIST ITEMS BELOW) `� ❑ 9 i commencing with Section 7000) of Division 3 of the Busi- ness and Professions Code, and my license Is in full force and PAVG e;feet RKI SPACES REO'D PROVIDED II��JJ License Number Lie Class LIMITED TIME USE Contractor Date DATE DATE ❑ I am exempt from the licensing requirements as I am a FROM TO licensed architect or a registered professional engineer SIZE OF NO OF INSPECTOR'S acting in my professional capacity (Section 7051, Bus- EXISTING BLDG STORIES SIGNATURE mess and Professions Code). PRESENT USE OF BUILDING t� ° FINAL APPROVAL ��/� �� - Lie or Reg.No Date r HOME OWNER-BUILDER DECLARATION No of EXISTING BUILDINGS ON LOT AND USE I hereby affirm that I am exempt from the Contractor's 4 1 0,7J A License Law for the following reason (Section 7031 5, Busi- ness and Professions Code) NO PARKING SPACES PROVIDED EJI, as owner of the property, will do the work and the # 0 0 0,o 88 structure is not intended or offered for sale (Section 0 0 0 0 0 0 o z 7044, Business and Professions Code). PROPOSED USE OF BUILDING O'S 0 1 -8 1 3 CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued(Sec 3097,Civ.C.) Lender's Name PROPOSED MAX OCC. Lender's Address PERMIT FEE I certify that I have read this application and state that the T above information Is correct I agree to comply with all County ISSUANCE FEE / ordinances and State laws relating to building construction, TOTAL FEE and hereby authorize representatives of this County to enter I upon the above-mentioned property for Inspection purposes. SEE REVERSE FOR EXPLANATOR LANGUAGE Si f Perm tee ate�J 2� t;'OFC;:ERS'CO\SPENSA1ION DECLARATION CGn875(11-a4) M ISCELLANEOUS APPLICATION I hereby affirm that I have a certificate of consent to self COUNT' OF LOS ANGELES BUILDING .AND SAFETY DIVISION mcure. or a _-ertificate ofWorkers'Compensat,on Insurance,or LJ a certified cop} thereof(See 3800.Lab.C) Policy No -Company B'UILDING9570& 9574 LdSTunaS Dr. P ) FOR APPLICANT TO FILL IN ADDRESS Certified cop} is hereby furnished BUILDING ADDRESS 9570 & 9574 Las Tunas Dr. LOCALITY Temple City Certified cop} is filed with the counts building inspection LOCALITYTem le City NEAR T Temple City Blvd. department P Y emp Y Date___ Applicant NEAREST /-� a. DISTRICT NO GROUP TYPE CESSED BY �O CONST CERTIFICATE OF EXEMPTIONFRODI WORKERS' CROSS ST Temle City Blvd.LEGAL COMPENSATION INSURANCE DESCRIPTION LOT NO BLOCK HIGHWAY rvo (CIRCLE) STATE MAJOR SECOND LOCAL NO OF BLDGS (This section need not be completed if the work Involved TRACT NOW ON LOT USE ZONE SPECIAL CONDITIONS by the permit is for one hundred dollars (5100) or less.) USE OF SIZE OF LOT EXISTING BLDG C 1 certify n that in the performance of the ork for ii high this permit is issued. I shall not employ any person m any Ow manner Tr% Zaccoll Domenic ZdCC01 '' so as to become subject to the Workers' Compensation Laiss OCCUPANCY GROUP -- MAIL 9578 Las Tunas Dr. ADDRESS - Date Applicant TEL OCCUPANT I LOAD NOTICE TO APPLICANT If, after making this Certificate of cITY Temple Cit No Exemption. you should become subject to the Workers APPLICATION FOR EXIT H4RDlNARE Compensation provisions of the Labor Code. you must forth ❑ ,.kith comply with such provis.ons or this permn shall be TRAILER USE LI GEOI-CGY INSPECTION ❑ No Spec Knowl deemed revoked LICENSED CONTFACTORS DECLARATION OCCOPANC� INS-ECTIONRg Panic Devices hcreb\ affirm that I an, licensed under provision;of Chapter sA�Erti f (FIs- ITEMS BELOW) 9 Icommenciitg «ith Section 7000) of Division 3 of the Bas!- NO OF EXITS ness and Professions Code and mi license is in full force and ?ARKING REO'D PROVIDED e_teCt ;PACES L cense Number Lie Class LIMITED TIME USE Contractor Daie DATE DATE rH M TD I am e\emp, from use hLensIns. requirements as 1 .in; i INSPECTOR S hcensed archnec-, o; ? regr.teree professional engineer slzE O= NO 0= SI NATUR ac*in_ in in% prcl:!ssional eamiciil �Senion 70) 1`BUY I EXISTING SLOG STOFIES mess and Professv�nsCoael f r1NAL APPROVAL IPG'=SENT USE DF BUILDING LIC o, Ree No Date HOME OWN-FR-BLILDLft DECLARATION NO O� EXISTING BUILDINGS ON LO- AND USE {} I hereby affnm that 1 an, e\emp: from the Contractor c License Lait for ine follov mg season (Section 7031 ; Bus,- ness and Professions Codes NO PARKING (� I 1 as ohne. of the pr�pe;*} «ill do we �iorl. ann the SPACES PROVIDED U structure i, not intended or offered to, s ile (Section 7043 Business find Professions Code1 X PRD-OSED USE OF BUIEDING CON'STRt1CTION LENDING AGENC:1 �_ �✓i „ „ I nerem affirm that there is - construction lending ai enc•, Bridal Photography for the performance of the wort. £or sshich this nermit is issued (Sec 3097 Cn C ) s Lender's Name PROPOSED MAX. OCC Lende;s Address PERMIT FEE 25.00 I certify mat I have read this application and state that the 1 above information is correct I agree to comply with all Counts- ISSUANCE FEE z7 ordinances and Siate laws relating to building construction and hereby authorize representatives of this County to enter TOTAL FEE 25.00 I i upon the above-mentioned property for inspection purposes �sr � SHE R£\'EBBE FOR EXP_ AN .TOP.y L 1NGLAGL Signature of Fermittee Date